Camden Coalition of Healthcare Providers Community Outreach for Complex Patients: Basics of Care Management and Care Transitions in the Field Kelly Craig, Director of Care Management Initiatives Jason Turi, Clinical Manager of Care Transitions July 20, 2012 www.camdenhealth.org

Overview Clinical model Program goals & guiding principles Evidence-based practice Team composition Daily admissions feed Care management: High risk Care transitions: Intermediate risk Q & A

Clinical Model “Care Management” “Care Transitions” Lourdes Cooper Virtua Data Assessment Assignment Triage Medically complex Socially complex 6-12 mos. engagement High Risk Quality improvement Patient engagement Care coordination Medical Home Medically complex 30-90 day engagement Interm. Risk Patients Flagged: 2+ hospital admissions < 6 months Selection Criteria: History of chronic disease related admits Rule out criteria Assigned to pathway “Care Transitions” www.camdenhealth.org

Outreach Program Goals Reduce preventable readmissions to the hospital; reduce costs for complex patients No open referrals; patients flagged and triaged from Health Information Exchange No duplicate services; we compliment services of existing providers Facilitate clinical coordination vs. direct care www.camdenhealth.org

Guiding Principles Enroll patients based on data; history of repeat admissions (high cost) and specific inclusion criteria Provide immediate and intensive follow-up coordination post discharge; connect patient to PCP as quickly as possible (target = 7 days post d/c) Dramatically improve the relationship between patient and PCP Equal focus of intervention on coaching www.camdenhealth.org

Outreach Team Composition High Risk Outreach Team Intermediate Risk Outreach Team RN MA LPN Health Coaches Social Worker www.camdenhealth.org

Daily Admissions Feed

Care Management: High Risk Hospital utilization in the city Appropriate vs. inappropriate 2 or more chronic health conditions Low socioeconomic status Homeless or unstable housing Lack of social supports Low-literacy, lack of HS diploma Behavioral health issues Generational poverty/urban violence www.camdenhealth.org

Care Management Workflow www.camdenhealth.org

Case Presentation #1 62-year-old male At time of enrollment, admitted for DKA (July 2011) History of homelessness Medicare/VA benefits Complex chronic conditions Diabetes Chronic kidney disease CHF COPD Substance use www.camdenhealth.org

Outreach and Intervention 2011 hospital utilization 3 ED visits 10 inpatient stays Contributors to hospital readmissions Main interventions Coordinated care with homeless services provider Arrange long-term care placement www.camdenhealth.org

www.camdenhealth.org

Care Transitions: Intermediate Risk History of 2 + admissions within past 6 months History of chronic disease related admits Socially stable Rule-out criteria Oncology Pregnancy-related Trauma Psych-only diagnosis

Evidence-Based Practices The Transitional Care Model: Mary D. Naylor, Ph.D., R.N.; University of Pennsylvania School Of Nursing The Care Transitions Program: Eric Coleman, M.D.; Division of Health Care Policy and Research at the University of Colorado Denver, School of Medicine

Care Transitions Workflow www.camdenhealth.org

Outreach & Intervention Enrollment & begin outreach at bedside Clinical assessment and first home visit within 24 hours of d/c Care plan, resource building, goals, medical records, etc. Schedule PCP appt within 7 days (target) Schedule specialty appointments within 14 days (target) Planned 30 - 90 day engagement

Patient Case Presentation #1 55-year-old African-American male At time of enrollment, admitted for GI bleed and SOB (November 2011) Medicare/Medicaid coverage Lives alone in high-rise apartment 12 medications daily 6 months prior to enrollment 9 ED visits & 6 inpatient stays Hospitalized on average every 45 days Complex chronic conditions ESRD Renal Carcinoma Hepatitis B Hypertension Hyperlipidemia Peripheral vascular disease Asthma Glaucoma (blind in one eye) Sleep apnea Severe back pain www.camdenhealth.org

Key Intervention: Home-Based Medication Reconciliation

Patient Centered Care Coordination Transport Meals Home PT/OT Home Nursing Hospital #2 Sub-Acute Rehab Durable Goods Hospital #1 Patient Dialysis PCP Urology Nephrology Oncology Surgery Optho Transplant Pain Mgt Cardiology GI www.camdenhealth.org

www.camdenhealth.org

Q & A Kelly Craig, MSW, LSW Director, Care Management Initiatives Kelly@camdenhealth.org 856-365-9510 x2004 Jason Turi, MPH, RN Manager, Care Transitions Jason@camdenhealth.org 856-365-9510 x2017